What is the treatment for gastritis symptoms?

Treatment of Gastritis Symptoms

Proton pump inhibitors (PPIs) are the first-line treatment for gastritis symptoms, with high-potency options like esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily being most effective for symptom relief and mucosal healing. 1

Initial Management Approach

First-Line PPI Therapy

• Start with high-potency PPIs rather than lower-potency options for optimal symptom control 1
  • Esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) 1
  • Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) 1
  • Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole) 1
• Take PPIs 30 minutes before meals to maximize effectiveness—inadequate timing is a common pitfall that reduces therapeutic benefit 1
• Continue treatment for 4-8 weeks depending on symptom severity and underlying cause 2, 3

H. pylori Testing is Mandatory

• All patients with gastritis must be assessed for H. pylori infection before finalizing treatment strategy 4, 1
• Use non-invasive testing: urea breath test or monoclonal stool antigen test 1
• If H. pylori is positive, eradication therapy is mandatory and fundamentally changes the treatment approach 4

H. pylori-Positive Gastritis Treatment

Preferred Eradication Regimen

• Bismuth quadruple therapy for 14 days is first-line due to increasing antibiotic resistance 1
  • High-potency PPI (esomeprazole or rabeprazole) twice daily
  • Bismuth subsalicylate
  • Metronidazole
  • Tetracycline
• Concomitant 4-drug therapy is an alternative when bismuth is unavailable 1
• Higher-potency PPIs improve H. pylori eradication rates compared to standard-dose omeprazole 1

Critical Follow-Up

• Confirm successful eradication using non-serological testing (not antibody tests) after completing therapy 4, 1
• Failure to confirm eradication is a major pitfall that leads to persistent infection and complications 1
• Eradication heals gastritis and prevents progression to atrophic gastritis, particularly important in patients requiring long-term PPI therapy 4, 1

Special Clinical Scenarios

NSAID-Associated Gastritis

• Discontinue NSAIDs immediately if possible 1
• If NSAIDs must be continued:
  • Add PPI therapy for gastroprotection 1
  • Use the lowest effective NSAID dose for the shortest duration 1
  • Test and treat H. pylori before starting long-term NSAID therapy—eradication is beneficial and mandatory in patients with peptic ulcer history 4, 1
• Misoprostol (synthetic PGE1) reduces NSAID-associated gastric ulcers by 74% but causes diarrhea, abdominal pain, and nausea limiting its use 1

Atrophic Gastritis Considerations

• Long-term PPI use in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis 4, 1
• This underscores the critical importance of H. pylori eradication before initiating chronic PPI therapy 4
• Evaluate for vitamin B-12 and iron deficiencies in all patients with atrophic gastritis, especially corpus-predominant disease 4, 1
• Consider checking antiparietal cell and anti-intrinsic factor antibodies if autoimmune gastritis is suspected 4, 1
• Screen for autoimmune thyroid disease in patients with confirmed autoimmune gastritis 4, 1

Surveillance Requirements

• Patients with advanced atrophic gastritis (Stage III/IV OLGA or OLGIM) require endoscopic surveillance every 3 years 4
• Obtain biopsies from body and antrum in separately labeled jars when atrophic changes are present 4
• Autoimmune gastritis patients need individualized surveillance intervals, typically every 3-5 years 4

Adjunctive Symptom Management

Breakthrough Symptoms

• Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms while awaiting PPI effect 1
• H2-receptor antagonists (ranitidine, famotidine) provide faster symptom relief than PPIs but are less effective for mucosal healing 1, 3
• H2RAs are particularly less effective for gastric ulcers compared to duodenal ulcers 1

Common Pitfalls to Avoid

• Inadequate PPI dosing or premature discontinuation before completing 4-8 weeks of therapy 1
• Failure to test for H. pylori in all gastritis patients 1
• Relying on symptom resolution without confirming H. pylori eradication—this leads to persistent infection 1
• Using low-potency PPIs (pantoprazole) when high-potency options are available 1
• Incorrect PPI timing—must be taken 30 minutes before meals 1
• Failure to evaluate for vitamin B-12 and iron deficiencies in atrophic gastritis 4, 1